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Full text of "Interstate bus--automobile collision, Interstate Route 15, Baker, California, March 7, 1968"

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PB1 90207 



SS-H-3 



HIGHWAY ACCIDENT REPORT 



Adopted: December 18, 1968 



INTERSTATE BUS- -AUTOMOBILE COLLISION 



INTERSTATE ROUTE 15 



Baker, California 
March 7, 1968 



HV 
8079.55 

.U58 

68/12 



NATIONAL TRANSPORTATION SAFETY BOARD 
DEPARTMENT OF TRANSPORTATION 
WASHINGTON, D. C. 
20591 






GENERAL DISCLAIMER 



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FOREWORD 

This report and determination of probable causes of the 
occurrence are based upon information contained in reports of 
investigation conducted by the California Highway Patrol, the 
Bureau of Motor Carrier Safety of the Federal Highway 
Administration, a Trauma Research Team from the University 
of California under contract to FHWA, the personal observations 
of a Board Member who visited the scene, and data gathered 
independently by the Board. The recommendations contained 
herein are those of the Safety Board- 



TABLE OF CONTENTS 



Chapter Contents Page 

Synopsis iii 

I. Facts and Circumstances 1 

A. Description of Accident 1 

1 . Events to Moment of Collision 1 

2. The Collision Phase 5 

3. Events Following Collision 9 

B. Description of the Accident Site 10 

1. The Highway- -Interstate 15 10 

2. Traffic Control Devices 11 

C. Condition and Types of Bus and Auto- 
mobile 12 

1. The Bus 12 

2. The Automobile 14 

D. The Background, Experience, and 

Condition of the Drivers 14 

1. The Bus Driver 14 

2. The Automobile Driver 15 

II. Applicable Laws and Regulations 18 

A. Motor Vehicle Operation 18 

1. California Vehicle Code 18 

2. Federal Regulations: Department of 
Transportation 20 

in. Analysis of Causal Factors 24 

A. Collision Occurred between the Bus and 

the Automobile 24 

1 . The Bus 24 

2. The Driver of the Wrong -Way 
Automobile was under the Influence 

of Alcohol and Carbon Monoxide 26 

3. The Automobile was Traveling the 

Wrong Way on the Divided Highway ... 30 

4. Automobile Driver's Ability to Read 
and React to Traffic Signs, Signals and 

Ma r king s 31 



Chapter Contents P^ge 

B. Bus Overturned and Burned 33 

1 . Bus Overturn 33 

2. Escape Possibilities for Passengers in 

the Middle of the Bus 34 

3. Possibility of Safety Belts Reducing the 
Severity of Injuries to Bus Occupants . . 36 

4. Bus Fire 37 

5. Statistics Relative to Bus Overturn 
Accidents 39 

6. Fatal Injuries to Automobile Driver ... 40 

IV. Conclusion and Probable Cause 41 

A. Conclusions 41 

B. Probable Cause 45 

V. Reconnmendations 47 

Appendix 

1. Severity of Impact Felt by Bus and 
Passenger Car 

2. Summary- -State of California Wrong Way 
Driving Reports 

3. Bureau of Public Roads Instructional 
Memorandum 21-6-67: "Signs and Pave- 
ment Markings to Avert or Redirect 

iVrong-Way Traffic Movements" 

4. Government of the District of Columbia 
Blood-Alcohol Chart 

5. Uniform Vehicle Code Implied Consent 

Illustrations 

1. Photograph- -Damage to Front of Bus 

2. Accident Diagram 

3. Photograph- -Severed Power-Steering Fluid 
Line 

4. Diagram of Known and Deduced Seating 
Locations, Ages and Sex of Bus Occupants 

5. Photograph- -Interstate 15 Looking East 
from Accident Site 

6. Photograph- -Inter state 15 Looking West 
from Accident Site 

7. Photograph- -Baker Interchange 



SYNOPSIS 

'-'On March 7, 1968, at 3:50 p.m., a 1964 Chevrolet two-door sedan driven 
by a man under the influence of alcohol and carbon monoxide, traveling west 
(wrong way) in the eastbound lanes of Interstate 15, 3 miles east of its 
intersection with California route 127, near Baker, California,, collided with 
an interstate bus. Both vehicles were being driven at normal freeway 
cruising speed. 

The bus overturned and was subsequently gutted by fire, resulting in 
the death of 19 of the 30 passengers. The 11 survivors suffered injuries that 
varied from minor to severe. 

The automobile driver was killed instantly by impact forces and then 
ejected from the car. The automobile caught fire from the bus fire and was 

also gutted. ( ) -^ 

Just prior to the accident, the bus driver, in the process of passing 
a slower moving eastbound vehicle, suddenly realized that the vehicle 150 
to 200 yards ahead of him in his lane of traffic, was traveling toward him. 
The bus driver made a severe brake application and steered hard to his 
left toward the wide, clear median, in an unsuccessful attempt to avoid a 
collision. 

The automobile driver, described by his roommate as "too drunk to 
drive, " left Baker at approximately 3:40 p.m., driving east towards Las Vegas 
on Interstate 15. At some point east of Baker, the driver reversed his 



direction of travel from eastbound to westbound so that he was then 
driving in the wrong direction on the eastbound roadway. It was too 
late vi^hen he realized that the eastbound bus was approaching in the 
same lane. He made a severe brake application and steered hard to 
his right toward the median. His evasive action was too late to avoid 
the collision. 

Rapid propagation of the ensuing fire and inaccessibility of escape 
facilities gave the passengers in the middle of the bus little or no 
opportunity to be evacuated or rescued. 

Probable Cause : 

1. The Collision was caused by the driving of an automobile 
the wrong way on a divided highw^ay, colliding head-on 
with an interstate bus being driven in the proper direction. 

2. The Injuries to the bus occupants were caused by the forces 
of impact and subsequent bus overturn in the absence of 
crash injury prevention facilities such as occupant safety 
belts. 

3. The Fire was caused by pow^er- steering oil being discharged 
under high pressure from a broken fitting damaged by the 
collision, and ignited by exposed electrical circuits in the 
front of the bus. This fire then ignited the dies el oil spilled 
from the ruptured fuel tank of the bus. 

4. The 19 bus passenger Fatalities w^ere caused by the rapid 
propagation of fire and inaccessibility of escape facilities, 



coupled with injuries and disorientation, preventing escape 
or rescue of the non-fatally injured bus passengers. 

Contributing causes to the occurrence of the collision were : 

1. The automobile driver was under the influence of alcohol 
and carbon monoxide, resulting in his failure to realize 
that he was on a one-way divided highway and not on a two- 
way highway. 

2. Lack of traffic control devices (signs, signals, markings) 
between entrance and exits to the highway in the vicinity 
of the accident to advise the automobile driver of the 
proper direction of travel. 

3. Failure of the automobile driver to react to the danger of 
the approaching bus in sufficient time to take adequate 
evasive action. 

4. The fact that the bus driver did not identify the direction 
of travel and potential danger of the wrong'-way vehicle 
in sufficient time to permit him to take adequate evasive 
action. 



- 1 - 

I. FACTS AND CIRCUMSTANCES 

A. Description of Accident 

1 . Events to Moment of Collision 

The bus, on a through schedule between Los Angeles, California, and 
Las Vegas, Nevada, departed from the Los Angeles terminal at 12:01 p.m., 
March 7, 1968, with 30 passengers on board. In accordance with company 
policy, it was operating with its headlights burning. The bus passed the 
second of two interchanges serving Baker, California, at approximately 
3:45 p.m. Continuing eastbound on Interstate 15, in the outside (right) lane, 
the bus came upon a slower-moving vehicle, a pickup truck pulling a 
camper trailer, and changed to the inside (left) or passing lane, to overtake 
and pass this vehicle. The bus, traveling at 60 to 65 m. p. h. , slowly 
pulled abreast of the vehicle. The bus was in the passing lane, in the 
process of passing this vehicle, for a period of a minute or two before the 
collision. 

Suddenly, the bus driver realized that the vehicle in his lane, 150 to 
200 yards ahead of him, was not traveling in the same direction but was 
driving in the wrong direction, coming towards him. Due to the speeds of 
the t^vo vehicles and the short distance betw^een them, there was 
insufficient time for the bus driver to take adequate evasive action to avoid 
a collision. 

One passenger, who identified himself as a race car driver, was 
seated on the left side of the bus at the aisle, two sections behind the bus 



- 2 - 

driver. This passenger indicated that he did not trust other people's 
driving; therefore, he was continually monitoring the bus driver and the 
roadway. When he saw the wrong-way driver approaching, he did not 
think that the bus driver had observed him. He was just starting to yell 
at the driver when he saw the driver begin to pump the brakes and sharply 
turn the bus toward the median strip. 

Deciding that he would be unable to move to his right because of the 
slower-moving vehicle, the bus driver made a severe brake application and 
steered hard to his left toward the wide-clear median. The rear wheels of 
the bus left tire marks on the pavement, 123 feet for the right wheels and 
47 feet for the left rear wheels, to the point of impact. At the moment of 
impact, the speed of the bus had been reduced to between 20 to 30 m. p.h. 

Michael Leo Barry, the driver of the wrong-way automobile, left 
Baker at approximately 3:40 p.m., headed for Las Vegas, which is 94 
miles east on Interstate 15. The driver had been drinking for a period of 
6 1/2 hours prior to the accident, and in the opinion of those who observed 
him and were with him, he was intoxicated. 

The driver of the w^rong-way automobile was employed as a short-order 
cook by Pike's Cafe in Baker. He reported for work on the day before the 
accident (March 6), and was not allowed to work because it was felt he was 
intoxicated. He returned to Pike's Cafe at 9 a.m. on the day of the accident. 
He was still in an intoxicated—' condition and was suffering from a "hangover" 
which was so severe that he could not hold a cup of coffee in hLs hand. He 



2_/ See Chapter III, Analysis of Causal Factors, Section 2, pages 26 through 



- 3 - 

told the manager that he wanted to quit his job and be paid off, but was 

told to go home and sleep it off and to come back at Z;30 p. m. 

Between 9 a.m. and 2:30 p.m. , the driver consumed a quart of 
wine and drank at least two, and possibly more, cans of beer at the local 
bus station. 

Accompanied by his roommate, he returned to Pike's Cafe at 
2:30 p. m. and was given the pay he had coming. They went to a local 
bar where Barry drank at least two more cans of beer. While they 
were at the bar, Barry left to go to the trailer to pick up some records 
he wanted to return to a girl friend in Las Vegas, and then returned to 
the bar. The roommate reported later that during this visit to the trailer, 
Barry stole $48 of his personal funds. They separated and Barry was 
last seen sitting in the automobile in front of the bar at about 3:40 p.m. 
This time could not be verified. 

During the day of the accident, Barry drove about the town of 
Baker. Those he came in contact with were cognizant of his intoxicated 
condition, and several people knew that he intended driving to Las Vegas. 
Ke was described as mean drunk, argumentive, and loud. A fellow 
employee, and Barry's roommate declined to accompany him to Las 
Vegas with the comment that Barry "was too drunk to drive. " Of those 
who were cognizant of his condition, no one except his roommate made any 
effort to dissuade or prevent Barry from driving about town or to Las 
Vegas. The manager of Pike's Cafe admonished him for the reckless 
manner in which he drove in the parking lot, but did not suggest that 



- 4 - 
he not drive in his condition. Police services were available if anyone 

wanted them. Baker has a constable and access to the sheriff and 

Highway Patrol. 

At about 3:40 p.m. Barry left Baker for Las Vegas. At some point 
east of Baker, Barry reversed his direction of travel from eastbound to 
westbound so that he was then driving in the wrong direction on the 
eastbound roadway. This reversal of direction of travel could have been 
accomplished in either of two possible maneuvers. These are discussed 
in Chapter III, Analysis of Causal Factors. 

Between the unknown point where he changed his direction of travel 
and the point of impact (this distance is known to have been at least 3 
miles), the wrong-way vehicle forced at least five eastbound vehicles to 
take evasive action in order to avoid it. Five witnesses testified that they 
were driving east on Interstate 15, and that they saw the wrong-way 
automobile when it was Z to 3 miles east of the point of collision. Each 
encounter was separate from the other. These vehicles were in the inside 
(left) lane, attempting to pass slower-moving vehicles, when they saw the 
automobile approaching them. They saw the vehicle while it was far 
enough ahead of them to enable them to reduce speed, change lanes to the 
right, and avoid a collision. The drivers of these vehicles also had time 
to try to attract the wrong-way driver's attention (blowing horns, flashing 
headlights, waving arms, shouting) to the fact that he was driving in the 
wrong direction. All of these efforts were to no avail. The witnesses 
said the wrong-way driver was driving at highway speed (70 m. p. h. posted 



- 5 - 
speed limit) and acted unconcerned "as though he was out on a Sunday- 
afternoon drive. " 

As the driver approached the eastbound bus, he apparently realized 
that the bus was not going to get out of his way. He made a severe brake 
application and steered to his right toward the wide, clear median in an 
unsuccessful attempt to nniss the bus. The car left tire marks on the 
pavement, 84 feet for the left wheels and 2Z feet for the right wheels, to 
the point of impact. At the moment of impact, the speed of the automobile 
had been reduced to between 50 and 60 m.p. h. 

Z. The Collision Phase 

The bus and automobile collided head-on as indicated by damage to 
the front of the bus from its left headlights through the right front corner 
(Illustration 1), and to the frontal area of the automobile. 

At the moment of impact, the bus was being steered to its left and 
the automobile to its right, resulting in a collision at an oblique angle. 
The longitudinal forces at impact resulted in vehicle deformation and 
deceleration. Because of the -weight difference, the automobile suffered 
much higher deceleration and deformation than the bus. The automobile 
•wsls driven backward approximatel-y 45 feet by the bus and v^as rotated in 
a clock-wise direction (as seen from above) along the right side of the bus. 
As the bus slid to a stop in the sandy median, it overturned onto its right 
side, perpendicular to the roadway, 53 feet from the point of impact. (See 
Illustration 2. ) 



- 6 - 

The front of the bus was severely damaged by the impact in increasing 
severity from the left through its right front corner, primarily in the 
area below its windshield. The right front wheel assembly, including 
suspension members, was pushed rearward through a bulkhead, penetrating 
and compressing the fuel tank (located immediately to the rear of the right 
front wheel well), and contributing to damage and distortion of the plywood 
floor of the passenger compartment. The fuel tank contained approximately 
115 gallons of diesel fuel. The battery compartment, which was located 
immediately to the rear of the fuel tank, was also partially crushed and 
displaced. Both sections of the windshield were ejected from their mount- 
ings upon impact. The overturning motion of the bus did not contribute 
materially to further mechanical damage to the bus. The seats were not 
dislodged from their floor anchorages as a result of the collision. 

The full front of the automobile was crushed rearward, with its 
general alignment changed, so that the front area of the body and frame was 
deflected to the right. There was severe buckling damage to the right side, 
and impact damage to the left side, with the left door assembly protruding 
outward and downward. The roof was damaged and the trunk lid buckled. 
The two front tires were ruptured and torn by the impact. The left rear 
tire was shredded during the lateral motion of the automobile following 
impact, and the right rear tire remained inflated. The gasoline tank was 
not damaged or dislodged from its mountings, and examination following 
the accident disclosed that it contained approximately 15 gallons of gasoline. 



- 7 - 
The left rear window -was down, the left front window was down 4 to 5 
inches, the right front window was up, and the right rear window was 
damaged to such a degree as to prevent a determination. The glass in 
the se -windows and the windshield was broken. 

The interior of the automobile was subjected to intense fire, fueled 
by splashed diesel fuel from the bus. All combustible materials, such as up- 
holster^'', interior linings, floor mats, plastic items, and the spare tire which 
was in the back seat area were consximed by fire. A small portion of the 
trunk area behind the rear seat was burned. There was no evidence of any 
fire found in the heavily damaged engine compartment. 

The left exhaust manifold of the automobile had a hole approximately 
1 1/4 inches wide and 3 inches long located in its top frontal area. 

The bus driver and passengers in the bus were unrestrained in 
their seats. The bus, like typical intercity buses, was not equipped with 
seat belts. The passengers and the bus driver were thrown forward 
and slightly to the right upon impact. Due to the mass of the bus and 
the partial collapse of its frontal area, they experienced fairly low rates 
of deceleration. 

When the bus veered sharply to its left and then overturned onto its 
right side, some of the right w^indows were broken as passengers lurched 
and fell against them. During the process of overturn, the bus body w^as 
twisted causing some of the emergency exit type windows to be sprung 
open. Portions of bodies, such as legs, arms, and hands. 



protruded through the window openings. As the bus came to rest on its right 
side, at least three persons were pinned by the weight of the bus lying on 
their protruding extremities. As the bus turned over onto its right side, 
those passengers who were seated on the left side were thrown toward the 
right side. An evaluation of the injuries sustained by the surviving 
passengers indicated that one was critical, five were moderate, and five 
were minor. 

Upon impact, the bus driver was thrown forward against the steering 
wheel and instrument panel and then toward the right side of the bus. He 
suffered a broken leg, one broken rib, and second-degree burns to both 
hands. His injuries prevented his rendering any assistance to the passengers 
in their attempts to escape from the bus interior. 

Upon impact, the automobile driver struck the steering wheel and 
column, which were forced upward, the dashboard, and the left A-piirar, 
and was ejected through the left door as the automobile rotated along the 
right side of the bus. He was killed instantly upon impact. His body was 
foxind near the rear of the bus, adjacent to its roof. The automobile was 
equipped with seat belts which were not in use at the tirne of the accident. 
The coroner's report stated that death was immediate d.nd resulted from 
multiple lacerations of the heart from fractured ribs. His body subsequently 
received second- and third-degree burns of the head, hands, and forearms 
as a result of the ensuing fire. 



- 9 - 

3. Events Following Collision 

During the collision phase, fire immediately broke out in the front 
area of the bus, fueled initially by vaporized power- steering oil, and 
shortly thereafter by diesel fuel. The power- steering oil was discharged 
from a fitting at the base of the bus steering column which was broken in 
the collision. (See Illustration 3. ) The diesel fuel was sprayed, splashed, 
and spilled over a large area of the bus, including the baggage and 
passenger compartments. The fire spread and grew rapidly in intensity. 

The bus driver and six passengers escaped through the right wind- 
shield area, some with assistance. Five passengers escaped through 
the rear window of the bus which was opened forcibly by one of the 
passengers, who then rendered assistance to others. 

The passengers who were seated near the front and near the rear of 
the bus, and on the left side, comprised the majority of the escapees. Of 
11 surviving passengers, nine had been seated on the left side of the bus 
within four rows of the front and three rows of the back. The two surviv- 
ing passengers in the right-hand seats were seated in the aisle seats of the 
first and fourth rows. (See Illustration 4. ) 

The 19 passengers who did not escape, either due to injuries sustained, 
shock, or disorientation, combined with limited routes of escape, were 
quickly overcome by smoke, lack of oxygen, and fire. They died in the bus. 

Autopsies were not performed on the nonsurviving passengers. The 
intense fire damage to the victims made normal identification impossible. 



- 10 - 
During identification procedures, a pathologist assisted the identification 

team. He partially examined 12 bodies and observed fractured extremities 

but no injuries which, of themselves, would have been fatal. 

B. Description of the Accident Site 

1 . The Highway - Interstate 15 

The accident occurred on Interstate Highway 15, the main arterial 
route between Los Angeles, California, and Las Vegas, Nevada. It has a 
high accident frequency rate. The accident occurred in the eastbound lane, 
3 miles east of the intersection of Interstate 15 and California Route 127, 
near Baker, California, which is located 192 miles northeast of Los 
Angeles, California. 

The highway at this location is a full four-lane, divided freeway, with 
two eastbound traffic lanes. The roadway runs generally east and west, is 
predominantly straight, and has a gradual upgrade to the east. The 
surrounding area is desert and there are no buildings, trees, or other 
obstructions to limit the visibility. (See Illustrations 5 and 6. ) 

The roadway consists of a 24-foot asphaltic concrete pavement, a 
10-foot blacktop shoulder on the right, and a 2-foot blacktop shoulder on 
the left. The eastbound roadway is separated from the opposing westbound 
roadway by a 78-foot, sandy median divider which conforms to the contour 
of the roadway. There were no surface defects in the roadway. At the 
time of the accident, 3:50 p.m. , the atmosphere was slightly overcast, 
with a light haze. Due to the overcast condition, the sun did not create a 
visibility or glare problem. There had been no recent precipitation. The 



- 11 - 

temperature at the time of the accident was 59 . — 

The nearest point of entrance to or departure from this highway is 
1 mile west of the accident site and consists of controlled access freeway- 
type on-and-off ramps serving Baker. 

2. Traffic Control Devices 

The maximum speed authorized is posted at 70 m. p. h. 

Pavement markings on the eastbound roadway of Interstate 15 consist 
of a 4-inch skip white center line with 9-foot segments of painted line 
separated by 15-foot unpainted gaps. 

"Wrong Way" and "Do Not Enter" signs, supplemented by white 
directional arrows painted on the road surface, are in place at the Baker 
off-ramp and entrance, (See Illustration 7.) 

The signs and directional arrow markings present at these locations 

were devised by the State of California to reduce the propensity toward 

4/ 
wrong-way movements.— Their effectiveness has been demonstrated by a 

reduction of wrong-way movements at interchanges throughout the State 

of between 60 and 70 percent.— (See Appendix 2. ) 



3/ Recorded by the FAA Weather Station, Daggett, California, located 
some 50 miles west of Baker, 3-7-68, 3:58 p.m.- 

4/ Wrong- Way Driving (Phase II), State of California, Highway Trans- 
portation Agency, Department of Public Works, Division of Highways, 
Traffic Department, February 1965. 

5^/ Wrong-Way Driving (Phase III), State of California, Highway Trans- 
portation Agency, Department of Public Works, Division of Highways, 
Traffic Department, June 1968. 



- 12 - 
C. Condition and Types of Bus and Automobile 

1. The Bus 

The bus was a 1966 Challenger, Model MC 5A, manufactured by- 
Motor Coach Industries, Inc. , Pembina, North Dakota. The overall 
length of the vehicle was 35 feet, with a wheel base of 261 inches. The 
height of the center of gravity of this bus was estimated to be 33 inches 
above the ground level at the time of the accident. The coach is equipped 
with an air-ride system which compensates for the load on the bus and 
maintains the vertical center of gravity at or near 33 inches. Its loaded 
weight was 28, 733 pounds. It was equipped with a rear-mounted diesel 
engine which was fueled from a 144- gallon capacity aluminum fuel tank 
located in a compartment behind the right front wheel well. Compart- 
mentalized directly behind the fuel tank were the two-level battery rack 
and the 212 cubic-foot luggage area. The flooring of the passenger 
compartment was constructed of five-ply plywood, one-half inch thick. 
The seats are bolted through the plywood flooring by means of a cap 
screw and nut combination, with a three-inch diameter metal plate 
under the ply-wood at each anchorage. 

Besides the outward- opening door, located at the right front, for 
boarding and alighting purposes, this bus had eight large, wide windows 
which were hinged at the top, opening outward to provide passenger 
escape under emergency conditions. The sash was held in the closed posi- 
tion by means of three spring-loaded latches attached to the window moulding. 



- 13 - 

Pulling up and out at any point on the moulding would allow the windows to 
be pushed open. Engraved instruction plates, mounted below each windo'w 
adjacent to each row of seats, provided the following information: "In 
emergency, all side windows can be used as exits. Jerk out and up 
anywhere on the moulding and push out on window. " 

In addition, the rear center window was designed for emergency 
escape and operated by pulling up on the bar at the bottom of the sash and 
pushing out on the window. Instructions for emergency use are also 
provided below this window. The two- section windshield was also 
designed for emergency escape, with its removal facilitated by heavy 
outward impact. 

The bus was designed to seat 39 passengers: one to a seat, two seats 
to a section, in two rows of nine sections, each; and one to a seat, three 
seats to a section, in one row located at the left rear of the vehicle, 
adjacent to a lavatory located at the right rear of the vehicle. 

An examination of the bus maintenance records at the Los Angeles 
terminal garage indicated that the bus had been driven approximately 
Z50, 000 miles and had received routine maintenance. 

The bus driver indicated that he had experienced no malfunction or 
difficulty in the operation of the bus, and that it was in excellent condition 
prior to the accident. 

Examination of the remains of the bus disclosed that the rear tires 
had original treads, with configuration depths from 11/32 to 13/32 of an 



- 14 - 
inch; the right front tire was destroyed by fire; and the left front tire 

was of original tread, with a configuration depth of 19/32 of an inch. 

An examination of the brakes disclosed no cracks or deformities, and 

brake linings were found to be of adequate thickness. 

2, The Automobile 

The automobile was a white 1964 Chevrolet Impala two- door sedan, 
equipped with a 327 cubic-inch V-8 gasoline engine and seat belts. It 
weighed 3, 490 pounds. 

The spare tire was being carried, unanchored, in the rear seat 
area of the car. 

The car was registered in the name of a female resident of North 
Las Vegas, Nevada, and bore Nevada license plate No. GM 9886. The 
car was reputed to be in good mechanical condition with no noticeable 
defects. 
D. The Background, Experience, and Condition of the Drivers 

1. The Bus Driver 

The bus was driven by Kenneth Leroy Burkhard, 41 years old, of 
Long Beach, California. He held a California chauffeur's license, No. 
B324203, and a physician's certificate, dated March 11, 1965, which 
indicated that at the time of examination, he was physically qualified to 
drive motor vehicles in operation, subject to the Federal Motor 
Carrier Safety Regulations. The examination certificate is good for 
a period of 3 years, and was to expire on March 11, 1968. 



- 15 - 

He had been employed by the carrier since May 11, 1956, and had 
been assigned to the Los Angeles-Las Vegas run for almost IZ years. 
According to company records, he had not experienced any chargeable 
accidents and was eligible for a 12-year safety award. Company officials 
rated Burkhard an excellent driver and a steady, conscientious employee. 
Burkhard had no record of traffic convictions in California, Nevada, 
or on file with the National Traffic Safety Data Center. 

Burkhard was in good health and had no financial or domestic problems. 
Burkhard was off duty for more than 24 hours, and had slept 10 hours 
prior to reporting for duty on the day of the accident. At the time of the 
accident, he had been on duty approximately 4 hours. 
2. The Automobile Driver 

The driver of the automobile was Michael Leo Barry, 39 years old. 
For a week prior to the accident he resided in a house trailer in Baker. 

Barry held a Montana driver's license. No. B290109, issued June 13, 
1966, and expiring on his birthday, January 9, 1968, 2 months prior to the 
accident. The expiration date is stamped on the upper left-hand corner of 
the driver's license. 

The Montana Highway Patrol record of driver's license examinations 
indicates that Barry was first examined for his ability to drive and 
knowledge of rules of the road on May 31, 1966. He failed the written test 
on the rules of the road. He was re-examined on June 13, 1966, and passed 
with the minimum score of 75. The records of the Driver's License 



- 16 - 

Division of the Montana Highway Patrol indicate that there has been no 
renewal of Barry's license since its expiration date. At the time of the 
accident, he was driving on an expired Montana driver's license. 

The application form, completed by Barry gave his address as 706 
North Z4th Street, Billings, Montana, and described the applicant as a 
white male, 5 feet 10 inches in height, weighing l65 pounds, and having 
brown eyes and brown ha'.r. The application indicated that Barry had no 
previous license to drive, that he never had a license suspended or 
revoked, that he was then married, and that he was employed as a cook. 

The National Traffic Safety Data Center has no record of this 
driver. Inquiries of all the States in which Barry is known to have 
resided produced no information of previous driver's licenses having 
been issued to him. This search produced evidence of only one traffic 
arrest, a conviction for a speeding offense in Nevada, on February 13, 
1968,. more than a month after his driver's license had expired. It is 
not known why his expired driver's license did not come to the attention 
of the authorities at that time. 

Barry had a criminal arrest record dating back to 1953, including 
five arrests for passing bad checks, two for public intoxication, one for 
burglary, and one for grand larceny. On December 10, 1962, under the 
alias of Raymond L. Decker, Barry was fined $25 and spent 5 days in 
jail after a conviction for being drunk and vagrant in San Bernardino, 
California. 



- 17 - 
Barry, a habitual, heavy drinker of alcoholic beverages, has had 

an alcohol problem for quite some time. His family described him as an 

unstable personality. He was depressed over his failure to get a song 

published. Because of his backgroxind and unusual driving actions, the 

possibility that Barry consciously committed suicide was considered. 

Pertinent factors contemplated were: 

1. He asked to get his job back when he got straightened out. 

2. He had stolen some money from his roommate. 

3. He had placed some phonograph records in the automobile to 
return to a girl friend in Las Vegas. 

4. He had asked others to accompany him on the trip. 

A chemical analysis performed on a blood sample taken from 
Barry's body during an autopsy conducted 48 hours after the collision 
(see Item No. 2 on page 28) determined that there was a blood-alcohol 
content of . 09 percent by w^eight and a 21 percent carbon monoxide 
saturation.— This condition impaired his ability to make sound judg- 
ments and to drive a motor vehicle safely. 

The blood sample used in the chemical analysis was "scooped" from 
the chest cavity of the driver's body. The heart had been severely lacerated, 
and blood vessels had drained and collapsed by the time the autopsy was 
performed. 



1/ Coroner San Bernardino County, Autopsy Report No. A.-213-68, con- 
ducted 3-9-68, re: Michael Barry, Jr., prepared by Dr. Wayne Scott, 
Pathologist, Root-Scott Medical Laboratory, San Bernardino, California, 
undated. 



- 18 - 

II, APPLICABLE LAWS AND REGULATIONS 
A. Motor Vehicle Operation 

1 . California Vehicle Code 

Section 21651, governing the use of public roads, states: "It is 
unlawful to drive any vehicle upon any highway which has been divided 
into two or more roadways by means of intermittent barriers or by 
means of a dividing section of not less than two feet in width either 
unpaved or delineated by curbs, lines, or other markings on the road- 
way except to the right of the barrier or dividing section, or to drive 
any vehicle over, upon, or across the dividing section, or to make any 
left turn or semi-circular or U-turn on any such divided highway, 
except through an opening in the barrier designated and intended by 
public authorities for the use of vehicles or through a plainly marked 
opening in the dividing section, " 

Section 21653 states: "No person shall operate or move a vehicle 
upon a street or highway designated and signposted for one-way traffic 
in a direction opposed to that indicated by the designation or signpost. " 

Section 23102, which covers driving while under the influence of 
alcohol, states in part: "It is unlawful for any person who is under the 
influence of intoxicating liquor, or under the combined influence of 
intoxicating liquor and any drug, to drive a vehicle upon any highway. . , 

Sections 13353 and 13354: The State of California has an implied 
consent law; however, presumptive levels of the percent by weight of 



- 19 - 
alcohol in a person's blood have not been established by the State of 
California to determine at what degree a person is legally under the 
influence of intoxicating liquor. 

Under an implied consent law, a condition is attached to the 
privilege of driving a motor vehicle upon the highvi^ays of a State, and 
every motorist is deemed to have given his (her) consent to a chemical 
test of his (her) blood, breath, or urine, to determine blood-alcohol 
concentration if charged with driving while in an intoxicated condition. 
A driver so charged may refuse to submit to a test and no test will be 
given, but his privilege to drive within the State is revoked. (See 
Appendix 5. ) 

Section 21350 gives basic authority to the Division of Highways to 
place and maintain traffic control devices. In order to carry out this 
responsibility, the Division of Highways adopted, and continually 
revises, a Planning Manual of Instructions - Part 8, Traffic. The 
standards in this Manual conform substantially to those used nationally 
in the Manual on Uniform Traffic Control Devices for Streets and 
Highways. 

Section 1-106 of the Planning Manual provides in part for research 
related to highway safety and the development of appropriate standards. 

Section 8-503. 30 of the Planning Manual establishes the policy 
that "Wrong Way" signs "be installed on all exit ramps . . , facing 
wrong-way traffic. " 



\ 

- 20 - 

The Planning Manual also provides for the installation of signs and 
markings at entrance locations advising drivers of the correct direction of 
travel. There is no authority or instructions for installation of traffic 
control signs and markings at other points. 

2. Federal Regulations: Department of Transportation 

Standards for traffic control devices are set forth in the Manual on 
Uniform Traffic Control Devices for Streets and Highways. This Manual 
was concurred in by the Federal Highway Administrator on November 26, 
i960, in accordance with Title 23, U. S. Code, section 109(d). A memo- 
randum dated July 25, 1962, from the Deputy Federal Highway Adminis- 
trator makes the use of this Manual mandatory in the case of all projects 
constructed with Federal-aid fund participation. 

Section lB-26 of the Manual prescribes that a "Do Not Enter" sign 
"shall be conspicuously placed in the most appropriate position at the end 
of a one-way roadway or ramp to prohibit traffic from entering the 
restricted section. It should normally be mounted on the right-hand side 
of the roadway, facing traffic entering the roadway or ramp in the w^rong 
direction. A second sign on the left-hand side of the roadway may be 
justified, particularly where traffic may be approaching in a turn ..." 

Section IB -28 of the Manual states that a "One Way" sign "should 
always be used, where applicable, and may be supplemented by a Turn 
Prohibition sign. " 

The Manual further states that "One Way signs are not ordinarily 



* - 21 - 

needed on the one-way roadways of divided expressways, where the design 
of interchanges indicates the direction of traffic on the separate roadways. " 

Section IB- 16 of the Manual states that a Turn Prohibition sign "is 
not needed at a ramp entrance to an expressway where the design is such 
as to indicate clearly the one-way traffic movement on the ramp. " 

The Acting Federal Highway Administrator issued Instructional 
Memorandum Zl-6-67, dated February 9, 1967, relative to signs and pave- 
ment markings to avert or redirect wrong-way traffic movements. This 
memorandum cited the serious nature of the wrong-way problem and 
directed that the Bureau of Public Roads "advise the States that we 
recommend the installation of additional signs and markings ..." A copy 
of this memorandum show^ing specific signing and pavement marking 
recommendations appears in Appendix 3 of this report. This is not a 
Federal regulation, but is a recommendation that invites voluntary 
compliance by State highway officials. 

Operations involving the transportation of passengers for compensation 
in interstate commerce by motor vehicle are subject to the Motor Carrier 
Safety Regulations of the Federal Highway Administration. The safety regu- 
lations, found in 49 Code of Federal Regulations, Parts Z90 to 296, include 
requirements concerning driver qualifications, the driving of motor 
vehicles, parts and accessories, accident reporting, hours and service of 
drivers, and vehicle inspection and maintenance. 

The following is -a partial listing and analysis of sections of Motor 



- 22 - 

Carrier Safety Regulations which in some manner pertain to this 
accident: 

§291 . 9, "Periodic physical examinations of drivers," states "Every 
driver shall be physically reexamined at least once in every 36 months 
and no person shall drive nor shall any motor carrier require or permit 
any person to drive any motor vehicle unless such person shall have been 
physically examined and certified by a licensed doctor of medicine or 
osteopathy as meeting the requirements of §291. 2. ..." 

§293. 84, "Floors, " requires flooring to be of substantial construction, 
free of all unnecessary holes and openings, and maintained so as to mini- 
mize the entrance of fumes, exhaust gases, or fire. There is no 
restriction against the use of wood as a flooring material. 

§293.93, "Buses, marking emergency doors, " requires emergency 
doors on buses to be marked and identified by a red electric lamp when 
buses are so equipped. The regulations do not require the installation of 
such a door. 

§293.61, "Window construction, " includes requirements on the 
adequacy of means of escape through bus windows, including a specified 
number of square inches of escape area per passenger and driver seating 
space. Also included is a push-out window requirement when openings are 
not glazed with laminated safety glass. No requirement is included in the 
regulations concerning escape means through floors or roofs in buses. 



- 23 - 

§293.63, "Windows, markings," requires push-out and escape 
windows glazed with laminated safety glass to be identified with appropriate 
wording to indicate they are escape windows and the naethods to be used for 
obtaining emergency exit. 

§296.2, "Inspection and maintenance, " includes a requirement that 
all push-out windows and emergency doors on buses be tested once every 
90 days. 

§293.65, "Fuel systems, " prohibits the location of the fuel tank 
forward of the front axle and prohibits placement of the tank within the 
passenger-carrying portion of any bus unless securely sealed off from 
such compartment by means of a substantial metal cover. The tank is 
also required to be of "substantial construction. " 

There is no Efederal regulation establishing criteria for the anchor- 
ing of passenger seats in a bus. There is a current notice of rulemaking 
in the Federal Highway Administration referring to performance 
requirements for the installation and attachment of passenger seats in 
buses (docket 2-11, dated October 1967, titled "Bus Seats"). 

There is a current rulemaking procedure in the Federal Highway 
Administration referring to seatbelt requirements for buses (initiated 
under Part II of the Interstate Commerce Act, docket Ex Parte No. 
MC-69, dated May 27, 1966) but no decision has been reached as of the 
date of this report. 



24 



III. ANALYSIS OF CAUSAL FACTORS 

General 

Several salient factors contributed in a causal way to this collision 
and the subsequent fatal and non-fatal injuries. In order to provide a full 
understanding of the facts and circumstances of the accident, it is 
necessary to identify all of the significant factors and their relationship 
to the accident. This analysis concentrates on those causal factors that 
are most pertinent in explaining the accident and are related to the 
corrective measures set forth in the recommendations. 

A. Collision Occurred between the Bus and the Automobile 

1. The Bus 

As the bus proceeded east on Interstate Highway 15, it canne upon a 
slower moving vehicle and moved into the left, or passing lane, in order 
to pass it. When the bus had moved into a position abreast of this 
vehicle, the driver suddenly realized that a white automobile was coming 
toward him in the same lane. 

Due to the fact that the bus driver did not recognize the danger 
presented b/ the wrong-way automobile until it had approached to within 
150 to 200 yards of his bus, he had very little time in which to evaluate 
the situation, decide what evasive action he should take, take that action, 



"* -15 - 

and avoid the oncoming car. Using a conservative estimate of the 
speed of the bus as 60 m. p. h. and of the automobile as 65 m. p. h, , 
the closing speed of the two vehicles was 1 25 m. p. h. or 1 84 feet per 
second. Using the closer estimate of 150 yards (450 feet), the two 
vehicles would close this distance to the point of impact in 2. 4 
seconds. If the distance was 200 yards (600 feet), the closing time 
would have been 3. 3 seconds. 

The longest tire mark left by the bus (right rear wheel) 
measured 123 feet. The longest tire mark left by the automobile (left 
rear wheel) measured 84 feet. Each of these tire marks was a result 
of a combination of braking action and the weight of each of the 
vehicles being shifted to the outside of its turn. 

At the moment of braking, the bus was traveling 60 m. p. h. or 
88 feet per second, and the automobile was traveling 65 m.p.h. or 94 
feet per second. The average speed of the bus during deceleration to 
the point of impact was approximately 63 feet per second. The 
average speed of the automobile during deceleration to the point of 
impact was approximately 85 feet per second. Using these speeds 
and the tire mark measurements, it can be assumed that the bus 
driver started his braking and turning actions approximately 2 seconds 
before impact, and the automobile driver's actions started approxi- 
mately 1 second before impact. 

It is reasonable to believe that the bus driver's actions, once he 



- 26 - 

overcarne the element of surprise, were quicker and more definite than 

those of the automobile driver who was driving while under the influence 

of alcohol and carbon monoxide. According to the bus driver's own 

statement, his attention was somewhat diverted by the problem of 

passing the slower moving vehicle; and he did not realize, until it was 

too late, that the vehicle in front of him, in the same lane, was coming 

toward him in the wrong direction instead of traveling with him in the 

same direction. 

The automobile driver may have seen the oncomiing bus in time 

to avoid the accident. However, his judgment and driving abilities were 

impaired by alcoholic and carbon monoxide influence. In this mental 

state, the fact that five other vehicles had changed lanes to avoid him 

may have led him to feel that the bus would likewise get out of his way. 

When he finally realized the true situation, it was too late to avoid the 

collision. 

2. The Driver of the Wrong -Way Automobile was under the 
Influence of Alcohol and Carbon Monoxide 

An autopsy was performed on the body of the automobile driver 

48 hours after the accident and indicated a blood-alcohol level of . 09 mg%. 

The blood sample used for the chemical analysis was taken from the 

chest cavity of the deceased, and not taken from the heart or any 

of the blood vessels. The blood found in the chest cavity after 

death was contaminated by other body fluids. This 



27 - 



circumstance was discussed with the pathologist who performed the chemical 
analysis. He indicated that the blood sample was not pure and, therefore, 
the blood-alcohol level reading was probably a low estimate. 

Using the amounts of alcoholic beverage reported to have been 
consumbed by the deceased during the 6 1/2-hour period prior to the collision, 
the following results can be computed: 



Known Alcoholic 
Beverage Consumed 



Contents of 100% 
Alcohol in Drinks Consumed 



4. oz 
1. 9 oz 



5. 9 oz 



1 quart of wine = 32 oz 

12. 5% alcohol by volume - 12,5 X 3 2 
4 cans of beer @ 12 oz ^ 48 oz 

4% alcohol by volume - . 04 X 48 
Total alcohol consumed 
Convert alcohol to equivalent 100-proof liquor in 

order to use the Body Concentration Table - 

5. 9 X 2 
Interpolate 11.8 oz to mg% of alcohol in the 

blood for 16 5 -pound man 
Conservative metabolic rate of 18 mg% per hour 

for 6 1/2 hours - 6 1/2 X 18 

Based upon the above computation, the blood- 
alcohol level should have been conservatively 151.7 mg% 

Based upon the above calculation, the blood-alcohol level reading at 

the time of collision should have been a minimum of 1 5 1 mg%. This 

i/ 
calculation is based upon a conservative estimate of a metabolic rate. 

Barry was described at 9:30 a.m. on the morning of the accident as being 



11. 8 oz 
268. 7 mg% 
1 1 7 . mg % 



J_/ Blood-Alcohol Chart prepared by the Government of the District of 
Columbia Department of Motor Vehicles. (This chart uses 15 mg% per hour 
as the metabolic rate, rather than the conservative value of 1 8 mg% per 
hour as used above. If the 15 mg% rate had been used, the blood-alcohol 
level would have been . 19 percent weight /volume. ) 12/64 (See Appendix 4. ) 



- 28 - 

in an "intoxicated condition. " Whatever blood-alcohol level he may have 
had at 9:30 a.m. would have to be added to the calculated 151mg% shown 

above. (151 mg%equals 0. 1 5% weight/ volume. ) 

2/ 
The Uniform Vehicle Code— defines "under the influence" as follows; 

"If there was at the time, 0. 10 per cent or more by weight of alcohol in the 

person's blood, it shall be presumed that the person was under the 

influence of intoxicating liquor. " 

3/ 
The Federal Highway Administration Standard 4.4.8— defines 

"intoxication" and "under the influence of alcohol" as a blood-alcohol 
concentration of 0.10% by weight or higher. 

The chemistry report of the autopsy also indicated a 21% concen- 
tration of carbon monoxide. CDR Schulte, MC, USN, in his article 

4/ 
"Effects of Mild Carbon Monoxide Intoxication"— states, "Impairment 

of functions due to exposure to carbon monoxide occurred earliest in the 

higher centers of the central nervous system and that area (or areas) of 

the brain which controls some of the cognitive and psychomotor abilities. 

Impairment is detectable at levels of carboxyhemoglobin below 5%, and 



2/ Uniform Vehicle Code, 1962, Section 1 1 -902(b)3, Persons under the 
Influence of Intoxicating Liquor, pages 130-1. 

V Federal Highway Administration Highway Safety Program Standard 
4.4.8, Alcohol in Relation to Highway Safety, dated 6/27/67, Section IB(1). 

4/ Effects of Mild Carbon Monoxide Intoxication, CDR John N. Schulte, 
MC, USN, Archives of Environmental Health, 7:524-530, 1963, p. 529-30. 



- 29 _ 

the degree of impairment increases with increasing concentrations of the 
carboxyhemoglobin in the blood. " The above refers to the effect upon the 
more complex psychological functions involving judgments, and 
situational decisions, and responses. This indicates that driving abilities 
of a person under the influence of carbon monoxide would be impaired to a 
degree in proportion to the percent of concentration. 

According to those who had ridden in the automobile previous to the 
accident, the car was in good mechanical condition. They reported no 
fumes or indication of exhaust system defects. At the time of the collision, 
the left rear window was all the way open and the driver's window was open 
4 or 5 inches. The automobile is not considered to be the source of the 
carbon monoxide. 

The source of the carbon monoxide is undetermined. Barry could 
have been exposed to carbon monoxide from one of at least two sources: 

a. From his living quarters. Barry and a roommate lived in a 
house trailer. The temperature was low during the night and, due to the 
cool weather, the heater was probably on to warm the trailer. The 
heater has not been examined, but could have been a source of carbon 
monoxide. 

b. From the smoke and funnes of the bus fire. The coroner's and 
autopsy reports stated the cause of death: "Laceration of heart, immediate, 
due to fractured ribs, immediate. " After impact, during which he 
received his fatal injuries, he was ejected from the automobile and came to 



- 30 - 
rest alongside of the overturned bus. As the bus burned, the body- 
received second- and third-degree burns of the head, hands, and fore- 
arms. If there were several post mortem reflex gasps as the body- 
lay next to the burning bus, some carbon monoxide could have been 
taken into the lungs. It is unlikely there was enough taken in to 
result in a 21% concentration after death. 

3. The Automobile was Traveling the Wrong Way on the 
Divided Highway 

The automobile driver left Baker on Interstate Highway 15 
traveling toward Las Vegas (east). At some point east of Baker, he 
reversed his direction of travel from east to west in the same road- 
way, so that he was then driving west (wrong way) in the eastbound 
lane of traffic. There are t-wo possibly -ways he could have reversed 
his direction: 

a. He could have entered the westbound roadwa-y of Interstate 
1 5 at the Baker Interchange and traveled east (wrong way) in the 
westbound lanes for an unknown distance, and then driven across the 
median in a U-turn and proceeded back toward Baker, now driving 
west (wrong way) in the eastbound lanes; or 

b. He could have entered the eastbound roadwa-y of Interstate 
I 5 at the Baker Interchange, proceeded eastbound to an unknow^n 
point, then made a U-turn in the roadwa-y and proceeded west (wrong 
way) in the eastbound lanes. 



- 31 - 
If the automobile driver entered into his wrong-way maneuver 
pursuant to "a." above, then the traffic control signs and markings at 
the Baker off-ramp were ineffective in their application in this 
instance. 

4. Automobile Driver's Ability to Read and React to Traffic 
Signs, Signals and Markings 

Those who came in contact with Barry prior to the accident, 
described him as being ''mean drunk, argumentive and loud. " The 
Board in its analysis of the reported amo\int of alcoholic beverage 
consumed by Barry, calculated that his blood-alcohol level was 
betw^een . 15 and . 19% by weight/ volume, but could have been higher. 
This, however, does not mean that he had lost all of his faculties, 
but it does indicate some degree of loss of coordination and judgment, 
and impairment of driving ability, which takes place well before a 
person reaches the "intoxication" stage. 

There is a difference between being "under the influence" of 
alcohol and varying degrees of drunkenness. In the common accept- 
ance of the term, "drunkenness" is taken to mean that a person is in 
a helpless state of immobility, as suggested in the quotation taken from 
Thomas Love Peacock's (1785-1866) Mistakes of Elphin, Chapter 3: 

"Not drunk is he who from the floor, 

can rise alone and still drink more; 



- 32 - 

But drunk is he, who prostrate lies, 

5/ 
Without the power to drink or rise. " 

Barry had not reached that state. He was able to drive the auto- 
mobile about the town of Baker, recklessly, it is to be granted, but he 
did not have an accident because he was not faced with an emergency. 
He was able to travel from place to place; talk with people; invite 
them to go with him to Las Vegas; take money from his roommate's 
dresser; and to decide to return borrowed records to a girl friend in 
Las Vegas. Therefore, it is logical to believe that he was able to 
read, comprehend and respond to traffic control devices, although 
probably not as well or as quickly as if he were sober. 

Since this accident, there has been another accident involving 
wrong-way driving on the same highway near Baker. The driver in 
this subsequent accident was sober. So, clearly, there is a need for 
more effective traffic control devices to advise motorists that they 
are driving the wrong way on highways of this type. Had such signs 
been in place along Interstate 15, it is possible that Barry would have 
reacted to them and avoided the accident. (See Appendix 2, item 7. ) 



5^/ Vehicle Traffic Law, Edward C. Fisher, p. 271, State vs. 
Myrick, 203 N. C. 8, 9, 164S.E. 328, 329, (1932). This is also 
quoted in Chemical Tests and The Law, by Robert L. Donigan, p. 294, 
published by The Traffic Institute, Northwestern University, 1966. 



- 33 - 

B. Bus Overturned and Burned 
1 . Bus Overturn 

The bus was steered sharply to the left, and the automobile 
sharply to the right, before speed was reduced sufficiently to remove 
inertial forces, tending to move the vehicles in a parallel axis to the 
roadway. As the vehicles vvere turning, they collided at an oblique 
angle. Both factors, combined, increased the centripetal acceler- 
ation of the bus front toward the center of its turn. 

As the bus was turning, the automobile, after being driven back- 
ward 47 feet, traveled momentarily along the right side of the bus, 
reducing the turning motion of the rear of the bus, while the top 
portion was unrestrained, resulting in the bus tipping to the right. 
This tipping action, combined with the loss of stability resulting from 
the right front wheel being driven backw^ard, caused the bus to turn 
over 90 onto its right side. 

The initial collision impact to the bus produced a relatively 
light forward impact upon most of the seated passengers. Calculations 
based on estimated speeds of the two vehicles at impact indicate that 
the bus would have been slowed from about 25 miles per hour to about 
17. miles per hour, resulting in a speed reduction of the bus as a 
vi^hole not greater than that involved in striking a fixed barrier object 
at 8 miles per hour. (See Appendix I. ) The actual decelerations upon 
passenger seats could not be estimated nor could they be compared with 



- 34 - 
existing bus crash-test results due to differences in the modes of 
immediate impact. However, the forward impact was not sufficient to 
dislodge seats from their attachments to the plywood floor by impact of 
passenger's body weight. 

After the forward impact, the bus turned farther to the left, but 
the overturn did not occur until the bus had come almost to a complete 
stop, as is indicated by the fact that the bus did not slide after the 
side of the bus contacted the ground. The bus had appreciable velocity 
in pivoting about its right tires in this overturn, and there was a 
lateral downward force on the bus body as the side contacted the 
ground, as is indicated by the slight lateral deflection of the bus roof. 
This deflection may have occurred when the bus rolled a few degrees 
beyond the flat-on-the -side position, concentrating the load on the upper 
part of the side of the body briefly, after which the bus settled back on 
its flat side. It is to be noted that the high position of passenger seats 
in buses tends to give these seats a greater velocity when striking the 
ground in overturn than would be felt in a passenger car, for example. 
Nevertheless, both the initial impact and the following overturn were 
crash conditions of relatively low impact velocity. 

2. Escape Possibilities for Passengers in the Middle of the Bus 
There -were two conceivable modes of escape for passengers at 
the center of the bus, both of which were so difficult as to be nearly 



- 35 - 

impossible. Passengers could have climbed upward, stood on the 
sides of the chair arms, forced the upper row of windows open, and 
then climed out onto the side of the bus. Escape from the fire would 
then have required an 8-foot drop to the ground. 

It was also possible for a passenger to move for^vard or rear- 
ward by walking on the side windows, passing through the openings 
between seat backs and the lower side of luggage rack, which would 
have been vertical in that position. These openings were quite narrow, 
and injured passengers were undoubtedly already occupying nnost of 
the side windows and the spaces between seat tops and bottom of the 
luggage rack. Another fore and aft path was offered by crawling 
along the sides of the seats; ho\vever, the vertical clearance here 
w^ould have been less than 2 feet, and it would have been necessary to 
bridge a gap about a foot wide at each seat opening. 

The degree of injury under non- severe impact conditions can be 
limited and escape can be facilitated by vehicle design. Perspective 
on the injurious outcome of this accident can be obtained by comparing 

it with a somewhat similar accident which occurred at LaGuardia field 

6/ 
on September 14, I960. This accident was investigated by the Safety 



6/ Civil Aeronautics Board, Bureau of Safety, Report of the Human 
Factors Group concerning an aircraft accident at LaGuardia Airport, 
New York, September 14, I960. 



- 36 - 

Board's predecessor, the Bureau of Safety of the Civil Aeronautics Board. 

In that accident, a commercial turbo-prop transport, carrying 70 
passengers, struck a dike while landing, overturned in the air, and 
struck the ground inverted. The aircraft then slid 900 feet to a stop across 
runway and unpaved areas. During this sequence, the safety-belted 
passengers remained in their seats, hanging upside down during the slide. 
After the aircraft had stopped, the passengers aided each other in releasing 
their belts, and despite smoke in the cabin, moved about successfully in the 
inverted cabin. All passengers and stewardesses escaped within 3 minutes, 
and many passengers brought their hand luggage. About half of the 
passengers suffered minor injuries, but these were not sufficient to delay 
evacuation. Shortly after the evacuation, a kerosene fuel fire spread to the 
cabin and destroyed the forward third of the cabin interior. 

The key factors in survival in the aircraft accident were the freedom 
from incapacitating injury due to the fastened safety belts and strong seats, 
and the accessibility of escape means to the uninjured passengers. 

The bus was not equipped with emergency exits in its roof or floor, 

and the fire spread too rapidly for all of the passengers to exit from the 

bus through the front windshield area or the rear window^. 

3. Possibility of Safety Belts Reducing the Severity of 
Injuries to Bus Occupants 

It is possible that if driver and passenger restraining devices had 

been provided and used, the occurrence and severity of injuries would have 



- 37 - 
been reduced. If the passengers on the left side of the bus had not fallen 
into the luggage rack and on top of the passengers on the right side during 
the time of turnover, there would have been fewer injuries and much less 
confusion and disorientation. Passengers restrained in their seats on the 
left side of the bus may have been able to open and escape through the 
windows designed as emergency escape routes. If the driver had been 
restrained in his seat, he would not have been thrown against the instru- 
ment panel, nor would he have fallen into the heavily damaged right front 
corner of the bus as it turned over. Had the driver been less seriously 
injured, he could have assisted in the rescue of passengers and, because 
of his familiarity with the bus, been effective in the evacuation of more 
passengers than w^ere saved. Also, if additional, accessible emergency 
escape facilities were available, the evacuation and/or escape opportunities 
of the passengers in the middle of the bus would have been improved. 

4. Bus Fire 

Fire started in the bus almost immediately upon impact. The fuel 
source of the initial fire was power- steering fluid under high pressure 
discharged in a fine mist from a broken fitting at the base of the steering 
column on the bus. The fluid, #10 lubricating oil, has a flash point of 
approximately 400 F. when vapors are generated. Due to high torque on 
the steering, there were probably more than 500 pounds of pressure per 
square inch generated in the power- steering system at the moment of impact. 
Such high pressure would cause discharge of the fluid as a fine mist vi^hich 
is highly flammable. 



Potential sources of ignition to the flammable vapors were numerous. 
Some probable sources of ignition in this accident were; (1) the sparks and 
heat friction caused by the contact between ferrous metals upon impact; 
(2) the hot brake assembly (surface temperatures on drxim and lining can 
exceed 800 F. as the result of one hard braking effort); (3) the headlights 
of the bus were burning up to the instant of impact (the temperature of the 
filaments was in excess of 4, 000° F. at the moment the headlight lenses 
were shattered); and (4) electrical circuits in the front of the bus, including 
those for the headlights, could have been short-circuited at the time of 
impact. 

The diesel fuel tank was compressed and punctured during the 
collision phase of the accident. This compression facilitated the spraying 
of diesel fuel, some of which was atomized, onto various objects, as 
discussed later. The fuel discharge was also prompted by inertial forces 
and the overturning of the bus. 

It is probable that some of the diesel fuel came into contact with the 
hot brake assembly of the right front wheel, resulting in vaporization. The 
most probable source of ignition of the vaporized and atomized fuel was the 
burning power-steering fluid vapors. The fuel tank was located behind a 
bulkhead immediately to the rear of the right front wheel well and was 
constructed of sheet aluminum. The tank was not equipped with any type 
of interior puncture -resisting bladder, reticulated fiber material, or self- 
sealing liner. 



- 39 - 
The fire propagated into and ignited combustible elements within the 

passenger and baggage compartm.ents. Splashed and sprayed fuel entered 
both compartments through damaged bulkheads and flooring following the 
bursting and puncturing of the fuel tank. The floor of the passenger 
compartment was damaged and distorted by impact forces transmitted 
backward from the collapsed right front corner of the bus and b/ the back- 
ward movement of the right front wheel assemibly. 

Upon being covered by diesel fuel, combustible fabrics and plastics in 
the seats, wall coverings, and the plywood flooring served as wicks for the 
burning of fuel vapors and also as a fuel for the growing, intense fire. 

Other combustible materials such as passengers' clothing, baggage, 
and package express, served as sources of fuel to the fire. 
5 . Statistics Relative to Bus Overturn Accidents 

Under current procedures, in use by national and State authorities, 
accidents are classified according to the primary cause, such as: failure 
to yield right-of-way; ran off roadway; excessive speed; improper lane 
usage; etc. Secondary causes, or contributing causes, are not included in 
the identification of the classification. This procedure does not provide for 
the classification of bus accidents as "overturn" accidents because they are 
classified according to the event that took place on the roadway and which 
occurred before the turnover. The lack of such statistics prevents the Safety 
Board from making any meaningful recommendation in this area. 

Consequently, there are no readily available meaningful statistics on 
bus overturn accidents, and the injuries and/or ejections of passengers. The 



- 40 - 
Federal Highway Administration (Bureau of Motor Carrier Safety) 

has investigated several such accidents during this calendar 

year. An outstanding example is the Carlsbad Cavern Coaches, Salt Flats, 

Texas, accident on December 16, 1967. During the accident, in which the 

bus skidded off the roadway due to "excessive speed for road and weather 

conditions, " the bus turned over several times, and nine of the 16 passengers 

and the bus driver were thrown out of the bus. 

The need for a more detailed analysis of accident events and 
statistics was recognized by FHWA in the development and distribution of 
the Highway Safety Standard No. 4.4. 10, Traffic Records. This standard 
requires that each State, in cooperation with its political subdivisions, 
shall maintain a statewide traffic records system which will identify and 
classify "Causes and Contributing Factors ..." for accidents. 

6. Fatal Injuries to Automobile Driver 

The deceleration forces on the automobile were such that fatal 
injuries were sustained by the driver upon impact. He was thrown forward 
into the steering wheel and column, the dashboard, and corner pillar, and 
ejected through the open left front door. He was not wearing the safety belt 
provided in the automobile. The crushing damage to the automobile and 
the severe change of direction of travel from forward to being instantane- 
ously driven backward by the decelerating bus, a speed change of approxi- 
mately 70 m. p. h. (See Appendix 1), resulted in immediate fatal injuries 



l_l FHWA Motor Carrier Accident Investigation Report No. 68-1, Bureau 
of Motor Carrier Safety, Carlsbad Cavern Coaches Accident at Salt Flats, 
Texas, on 12/16/67. 



- 41 - 
IV. CONCLUSIONS AND PROBABLE CAUSE 
A. Conclusions 

Based on the foregoing analysis of causal factors, the Safety Board 
has reached the following conclusions; 

1. The automobile driver was driving on an expired Montana 
driver's license. 

2. The automobile driver, at the time of the collision, had a 
higher level of blood-alcohol content that the . 09 mg% by weight reported 
in the autopsy report. 

3. The carbon monoxide influence increased the impairment of 
his driving ability already impaired due to alcoholic influence suffered 
by the automobile driver. 

4. The automobile driver was driving while under the influence 

of alcohol and carbon monoxide; and his judgment, reactions, and over- 
all driving ability were seriously impaired. 

5. The automobile driver did not consciously attempt to commit 
suicide. 

6. Among several people who were aware of the driver's 
alcoholic condition, and were in a position to dissuade him from driving, 
only one person attempted to do so. 

7. The automobile driver was driving in the wrong direction. 
Of the two possibilities for driving in the wrong direction, the most 
likely was that he entered the eastbound roadway of Interstate 15, at 
the Baker Interchange, proceeded eastbound to an unknown point, then 



. 42 - 

made a U-turn and proceeded west (wrong way) in the eastbound lane. 

8. Traffic control devices to advise motorists of the proper 
direction of travel were in place at the entrance to the Baker Interchange. 

9. There were no traffic control devices or pavement markings 
in place along Interstate 15, in the vicinity of the accident, to advise 
errant motorists that they were traveling in the wrong direction. 

10. The bus driver's attention was diverted by the problem of 
passing the slow-moving vehicle; and he did not realize, in time to avoid 
the collision, that the vehicle in the same lane in front of him was being 
driven the wrong way. 

11. Due to the automobile driver's impaired state, he probably did 
not realize that he was driving on a one-way roadway of a divided highway. 

12. Due to the automobile driver's impaired state, he probably did 
not realize that the bus was not going to get out of his way until it was 
too late to avoid the collision. 

13. Due to the overcast sky, the sun did not present a vision or 
glare problem to the automobile driver who was heading due west. 

14. The initial source of fuel for the fire was the fluid from the 
power- steering system emitted under high pressure. 

15. The ignition source was one of the following: 

a. Sparks and heat of friction caused by contacts between 
ferrous metals; or 



- 43 - 

b. Electrical components in use (i. e. , wires leading to 
instrument panel and headlights); or 

c. Hot filaments in broken headlights. 

16. The atomized and unatomized diesel fuel, which was ejected 
from the compressed and ruptured fuel tank, was ignited by the burning 
power. steering fluid. 

17. The injuries received by the nonsurviving passengers due to 
the collision and bus overturn were not fatal. 

18. All of the required escape facilities were not accessible to 
the bus passengers (i.e., the four side windows on each side of the 
bus). The Safety Board is cognizant of the fact that the National Highway 
Safety Bureau is working towards the development of a standard in this 
area. 

19. The absence of restraining devices for the driver and bus 
passengers made possible the increase in severity of injuries and 
resulted in confusion and disorientation (i.e., to the passengers on the 
left falling on the passengers on the right side of the bus). Had 
restraining devices such as lap-type safety belts been available and in 
use by occupants, it is probable that a greater number of persons would 
have been able to escape from the bus before the fire. 

20. The rapid propagation of fire and inaccessibility of escape 
facilities when the bus was lying on its side prevented the evacuation or 
rescue of those passengers in the middle of the bus. 



- 44 - 

21. The hole in the exhaust manifold of the automobile was caused 
by the collision. 

22. Federal Regulation 293. 65, as it applies to bus and diesel fuel 
tanks, provides only requirements for "construction" and "location, " 
requiring only that tanks be of "substantial construction'; the criteria 
are not precise and do not control effectively any necessary aspect of 
construction. The location of the fuel tank complied with the words of 
the regulation, but the location did not prevent the rupture. Federal 
Regulation 293.65 is indefinite and inadequate because it does not require 
any performance tests to determine any specific degree of resistance to 
external hazards, such as rupture and intrusion. 

23. Insofar as it is intended to control fire, Federal Regulation 
293. 84 does not assure any specific degree of resistance to fire because 
the words "substantial, " "unnecessary, " and "minimize" operate to 
release the designer from being required to provide fully effective fire 
blocking characteristics. The regulation speaks to design rather than 
tested performance. 

24. Federal Regulations relating to escape facilities for buses 
(Section 293. 61 (b). Bus Windows to be Constructed as a Means of 
Escape; Section 293. 63, Window Markings as Emergency Escape 
Facility; and Section 296. 2, Periodic Inspections of Emergency Exits) 
do not provide adequately for the timely escape of passengers for a 
predictable condition when a bus is lying on its side, as in this accident. 



- 45 - 

25. The automobile driver was not wearing the safety belt provided 
in his vehicle. 

26. The automobile driver suffered immediate fatal injuries due to 
the severity of the impact before he was ejected from the vehicle. 

27. Heat from the burning bus, resulting in second- and third- 
degree burns to the arms and head of the body of the automobile driver, 
had negligible effect on the blood-alcohol level determined during the 
autopsy 48 hours after death. ~ 

B. Probable Cause 

1. The Collision was caused by the driving of an automobile the 
wrong way on a divided highway, colliding head-on with an interstate bus 
being driven in the proper direction. 

2. The Injurie s to the bus occupants were caused by the forces 
of impact and subsequent bus overturn in the absence of crash injury 
prevention facilities such as occupant safety belts. 

3. The Fire was caused by power-steering oil being discharged 
under high pressure from a broken fitting damaged by the collision, and 



1/ Legal Me dic ine, Pathology and Toxicology, Dr. Umberger, Chapter 
on Alcohol. Professor Robert F. Borkenstein, Director, Police Admini- 
stration, Indiana University. Dr. Milton Halpren, Chief Medical 
Examiner, New York, New York. 



- 46 - 

ignited by exposed electrical circuits in the front of the bus. This fire 
then ignited the diesel oil spilled from the ruptured fuel tank of the bus. 

4. The 19 bus-passenger fatalities were caused by the rapid 
propagation of fire and inaccessibility of escape facilities, coupled with 
injuries and disorientation preventing escape or rescue of the non- 
fatally injured bus passengers. 

Contributing causes to the occurrence of the collision were : 

1. The automobile driver was under the influence of alcohol and 
carbon monoxide resulting in his failure to realize that he was on a one- 
■way divided highway and not on a two -"way highway. 

2. Lack of traffic control devices (signs, signals, markings) 
between entrances and exits to the highway in the vicinity of the accident 
to advise the automobile driver of the proper direction of travel. 

3. Failure of the automobile driver to react to the danger of the 
approaching bus in sufficient time to take adequate evasive action. 

4. The fact that the bus driver did not identify the direction of 
travel and potential danger of the wrong -way vehicle in sufficient time 
to permit him to take adequate evasive action. 



- 47 - 
V. RECOMMENDATIONS 

1. The Safety Board recommends that the Federal Highway 
Administrator expedite the proceeding initiated under Part II of the 
Interstate Commerce Act, docket Ex Parte No. MC-69, dated May 27, 
1966, "to inquire into the operations of motor carriers of passengers 
in order to determine whether it is necessary or desirable to adopt 
regulations and establish standards which would require carriers to 
install, provide, and maintain seat belts for the use of passengers and 
drivers. " The experience in this case indicates definitely that restraint 
of drivers and occupants in their seats under rollover conditions is 
necessary to reduce initial injury, disorientation, and thus insure more 
likelihood of timely post-crash escape from the vehicle. This report and 
the Safety Board's conclusion should be seriously considered by the 
Federal Highway Administrator in reaching his decision concerning a 
requirement that seat belts be available in buses. The Safety Board 
urges that a decision be made on this important matter which had been 
under consideration for more than 22 months at the time this accident 
occurred, and more than 30 months prior to the date of this report. 

2. The Safety Board recommends that the Federal Highway 
Administration, in its development of motor vehicle safety performance 
standards, review all motor vehicle fuel systems, including diesel fuel; 
and power steering, and brake systems. Also, in the establishment of 
crash barrier criteria, full consideration should be given to intrusion 
factors and flammability of fuels and fluids used in these systems. 



- 48 - 

3. The Safety Board recommends that the Federal Highway Adminis- 
tration review those characteristics of floors intended to be required 

by Federal Regulation 293. 85 (49 Code of Federal Regulations) with 
a view to rewriting the requirement in terms of specific and verifiable 
performance tests. This accident reveals that the fire resistance 
requirement for floors does not insure isolation of fires to any specific 
degree. 

4. The Safety Board recommends that the Federal Highway 
Administration revise Regulation 293.65 as it applies to liquid fuel 
tank requirements to specify crash impact resistance to rupture and 
intrusion in terms of performance tests that are applicable to all types 
of liquid fuel tanks -- including diesel fuel -- not just gasoline. 

5. The Safety Board recommends that the Federal Highway 
Administration include in its motor vehicle safety performance stan- 
dards a performance requirement concerned with the prevention or 
control of discharge from fuel tanks subject to compression ruptures 

or mechanical intrusion. Consideration should be given to existing means, 
such as liners of the self- sealing type, flexible bladders, and reticulated 
foam- filled tanks. A similar recommendation, applying primarily to tank 
trucks carrying flammable fluids, was made to the Federal Highway 
Administration in the Safety Board's report, released March 7, 1968, 
on the railroad-highway grade-crossing accident which occurred in-^ 



- 49 - 

Everett, Massachusetts, on December 28, 1966. This recommendation 
refers to Docket 3-2 of the National Highway Safety Bureau as well 
as to Motor Carrier Safety Regulations. 

6. The Safety Board recommends that the Federal Highway 
Administration continue its support— of State Highway Department 
research and application of remedial measures to avert or redirect 
wrong-way traffic movements at expressway, freeway, and multilane 
divided highway ingress and egress points. This research effort 
should be expanded and consideration given to the development and 
application of measures to avert or redirect wrong-way traffic move- 
ments which occur on a roadway at points other than those used for 
ingress and egress. Directional arrows applied at regular intervals, 
rumble strips, signs, and other signal systems might be considered. 

The Safety Board further recommends that the Federal 
High-way Administration advise the National Joint Committee on Uniform 
Traffic Control Devices of the effective measures developed to redirect 
wrong-way traffic movements which occur on a roadway at points other 
than those used for ingress and egress; and, urges the National 
Joint Commission to implement these measures on a National basis 
in the most expedient manner at its command. 



J^/ State of California Department of Public Works, Transportation 
Agency, Report on Wrong-Way Driving, Phases I, II, and III. 
Prepared in cooperation with FHWA, DOT. 



- 50 - 

7. The Safety Board recommends that the Federal Highway- 
Administration, as soon as possible, change the basis of its regula- 
tory requirements intended to insure escape from buses so that they 
are based upon tests of performance of occupants in escaping from 
buses standing or lying in all basic attitudes. In the development 

of test criteria, it is suggested that consideration be given to test 
procedures presently employed by the Federal Aviation Administra- 
tion for the regulation of the adequacy of escape techniques and 
systems. Further, consideration should be given to adopting for 
buses, the airline practice of placing emergency escape in tructions 
at each passenger location. It is further recommended that necessary 
regulations be expedited to insure that no new types of buses go into 
service which have not been tested to insure that all occupants can 
escape rapidly when the bus is in any of its basic attitudes after a 
crash. This recommendation refers to Docket Z-10 of the National 
Highway Safety Bureau, as well as to Motor Carrier Safety Regulations. 

8. The Safety Board recommends that the bus manufacturing 
industry and the motor carrier bus users consider the lesson of 
escape in this accident, and initiate their own performance tests of 
the escape capabilities of buses in each of their basic attitudes. 

9. The Safety Board recommends that the Safety Programs 
Services of the Federal Highway Administration develop a program 



- 51 - 

designed to produce a sense of individual responsibility in the general 
public to protect the Nation's highways from drinking drivers, enlisting 
in such a program the aid of the news media, the producers of alcoholic 
beverages, private and public agencies concerned with highway safety, 
as well as religious, educational, and civic groups to (a) support law 
enforcement efforts against and the prosecution of drinking drivers; 
■(b) impress upon the public individually, each person's serious social 
duty not to drive while under the influence of alcohol; and (c) individually 
to accept the responsibility of preventing other persons from driving 
■while under the influence of alcohol. 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD: 

Isf JOSEPH J. O'CONNELL. Jr. 



Chairman 



I si OSCAR M. LAUREL 



Member 



/s/ JOHN H. REED 



Member 



/s/ LOUIS M. THAYER 



Member 



Isl FRANCIS H. McADAMS 



Member 



Adopted: December 18, 1968 



APPENDIX I 
Severity of Impact Felt by Bus and Passenger Car 

The maximum severity of the impact which could be felt by each of the 
vehicles can be estimated in terms of changes of velocity experienced by 
each vehicle. The crash was almost directly head-on. The aspect of impact 
felt by the bus passengers was predominantly forward in the car impact phase. 
The velocity change in direct head-on crash can be calculated on an idealized 
basis and the results will give maximum values slightly higher than those 
actually experienced. 

The principle of conservation of momentum would apply. This principle 
is that the total momentum of both vehicles after impact is the sum of the 
momentum of each before impact. Expressed as an equation: 

(Weight of bus) X (Speed of bus) + (Weight of car) X (Speed of car) = 

(Weight of both vehicles) X (Speed after impact for both vehicles). 

For this purpose an eastward velocity is considered plus and a westward 

velocity is minus. 

(M^V^)+(M2V2)=M^V^ 
M-l = Estimated weight of bus and passengers 33, 000* 

V|^ = Estimated speed of bus at impact plus 25 m. p. h. * 

M2 = Estimated weight of automobile and driver 3,750* 

V2 = Estimated speed of automobile at impact minus 53 m. p. h. * 

*A1I figures rounded. 
(33, 000)(25) - (3,750)(53) = MfV^ 

825 X 10^ - 198. 75 X 10^ =3,675 X lO^Vf 
626. 25 = 36. 75Vf 
Final speed of both vehicles - V£ = 17. m. p. h. 

This means that in the impact, the speed of the bus was reduced from 

about 25 m. p. h. to about 17 m. p. h. , a reduction of only 8 m. p. h. 



From the standpoint of velocity change felt by most passengers, this 
reduction is to be compared with an impact against an unyielding object 
at 8 m. p.h. The car on the other hand, had its speed changed from about 
minus 53 m. p. h. to plus 17 m. p.h. The car was stopped instantly, then 
driven back in the opposite direction, so that its speed was changed by 
a total of about 70 m. p. h. 

This approximation is in general agreement with the observations. 
The car was pushed 43 feet backward from the point of impact. This 
idealized calculation is subject to many modifications but it indicates 
reliably that the reduction in forward bus speed caused by the original 
impact could not have exceeded 8 m.p.h. 



APPENDIX 2 

SUMMARY 

State of California 

II 
Wrong-Way Driving Reports 

These reports describe wrong-way driving on California freeways and 
expressways. For three separate 9-month periods, data was collected and 
analyzed to determine the effectiveness of preventive measures (special 
signs and pavennent arrows) installed on freeways and expressways. The 
before-and-after study method was used, giving consideration to both 
wrong-way driving incidents and accidents. In addition, 168 wrong-way 
drivers were interviewed, and biographical data is presented. 

The relative safety of various types of off-ramps was measured, and 
average rates of wrong-way entry are given. 

The study indicated the following: 

1. Statewide, the remedial measures reduced wrong-way driving 
60 percent on freeways and 70 percent on expressw^ays. 

2. More importantly, the measures reduced wrong-way driving 
accidents although to a lesser degree than wrong- way driving 
per se, 40 percent on freeways and 37 percent on expressways. 



1_/ State of California Department of Public Works, Transportation Agency, 
Reports on Wrong-Way Driving, Phases I, 11, and III. Prepared in coopera- 
tion with DOT, FHWA. 



-2- 

3. The measures were more effective in reducing the more severe 
accidents than the property-damage-only accidents. First year 
estimates indicate that 90 lives were saved, Z40 injuries pre- 
vented, and 140 accidents prevented. 

4. The special red retro- reflective pavement arrow was of no benefit. 

5. Wrong-way entry rates by interchange types -where all possible 

movements to and from the roadway -were provided are: 

Wrong-Way Entry Rate _2/ 

Interchange Type ( Incidents per 100 Ramp Years) 

Four-Quad Cloverleaf 2. 00 

Buttonhook 4. 12 

Two-Quad Cloverleaf 4. 91 

Diamond 7. 46 

Trumpet 17. 75 

6. One hundred and sixty-eight wrong-way drivers were interviewed. 
The driving record, felony conviction record, medical and mental 
histories of these driversi and of an additional 136 drivers involved 
in previous wrong--way driving accidents, w^ere examined. It was 

2^1 Ramp Year = D| + D +D3 + +D 

Where: Dj^ = Days of Observation at Ramp #1 
T^2~ Days of Observation at Ramp #2 
D, = Days of Observation at Ramp #3 
D = Days of Observation at Ramp #n 
and 365 days in 1 year. 



-3- 

found that, typically, the wrong way driver is not handicapped 
physically or mentally. However, he receives considerably more 
driving violation convictions and felony convictions than the 
average motorist. He is also involved in considerably more 
accidents of all types. 

Those wrong-v/ay drivers who were also involved in wrong-way 
driving accidents were found to have an even greater disregard 
for criminal laws than wrong-way drivers in general. 
7. Since many of the at-fault drivers in wrong-way accidents, 

especially the more severe accidents, have been drinking, and 
since it is generally assumed that the drinking driver is more 
difficult to influence, there was some concern that the preventive 
measures might not be too effective in reducing wrong-way driving 
by drinking motorists. The rate of wrong-way driving, however, 
was decreased to almost the same degree at night for the sober and 
for the drinking driver. During daylight hours, however, the drink- 
ing driver incident rate was decreased to a substantially greater 
degree (70 percent vs. 57 percent). 




APPENDIX 3 

U.S. DEPARTMENT OF COMMERCE 

BUREAU OF PUBLIC ROADS 

WASHINGTON. D.C. X0U5 



February 9, 1967 



INSTRUCTIOML MEMORANDUM 21-6-6? 

SUBJECT: Signs and Pavement Markings to Avert or 
Redirect Wrong-Way Traffic Movements 



Reports recently made available have shown that it is necessary to 
emphasize and broaden signing and marking practices for averting or 
redirecting wrong-way traffic movements. In view of the serious 
nature of the wrong-way problem, it is concluded that the Bureau 
should take steps to implement the installation of signs and pave- 
ment markings with no unreasonable delay. Accordingly, please 
advise the States that we recorrjnend the installation of additional 
signs and markings as described below and illustrated in the enclosed 
sketches. All locations should be investigated as soon as possible 
and necessary corrective action taken. 

It is recognized that in part these recommendations include signs 
(white on red, WRONG WAY signs) for which national standards attained 
through the Manual on Uniform Traffic Control Devices have not fully 
been developed. Since additional corrective action needed is gen- 
erally obvious, we recommend that it be done promptly without prejudice 
to future MUTCD determinations. 

1. Freeway and Expressway Exit Ramps (See Sketch A) 

a) ONE WAY signs, Turn Prohibition signs, and sign assemblies 
consisting of a DO NOT ENTER sign above a WRONG WAY sign 
should be placed where an exit ramp intersects a crossroad 
in a manner that may invite wrong-way entry. 

b) In addition, WRONG WAY signs desirably should be placed at 
locations along an exit ramp farther from the crossroad. 
Normally, siach signs should be located about at the mid- 
point of the ramp length between noses, at least 200 feet 
or more removed from the crossroad terminal signs, 

c) One or more arrow pavement markings also should be placed 
in each lane of an exit ramp near the crossroad terminal, 
at a location where it would clearly he in sight of a 
wrong-way driver. 



Page 2 

2. Freeway and Expressvay Entrance Ramps (See Sketch B) 

a) A ONE WAY sign visible to traffic on the entrance ramp should be 
placed on the side of the through roadway opposite to the 
entrance ramp. A NO TURNS sign may also be in place along the 
through lanes just in advance of an entrance ramp terminal. 

t) Route markers and directional signs, adequate in size and 

suitably positioned (overhead if necessary )_, shall be in place 
at an intersection of an entrance ramp and a crossroad. FREEWAY 
ENTRANCE signs have met wit'h some success in one State and may 
be used to supplement these guide signs. 

3. Roadways of Divided Highways having At-Grade Intersections (See Sketch C) 

a) ONE WAY signs should be in place visible to each crossroad approach 
at the far left position for the first roadway and at the far right 
position for the second roadway, if a divided highway has a median 
50 feet or more in width. For lesser width their use is optional. 

b) A sign assembly consisting of a DO NOT ENTER sign above a WRONG 
WAY sign may be placed on the right side of a divided highway 
roadway, at a location to be directly in view of ^ driver making a 
wrong-way entry from the crossroad. The same sigi^ assembly may 
also be placed on the left side of the divided highway roadway 
where the median width is such that the sign assembly is about 

Uo feet or more from the left edge of the opposite roadway. 

c) In addition, WRONG WAY signs may be placed at other locations 
removed from the intersection, along the right side of a roadway 
of a divided highway. These signs may also be pla,ced on the left 
side of a divided highway roadway at selected locations of 
sufficient median width as above described. 

d) Arrow pavement markings may be placed in each lane of a roadway 
of a divided highway in advance of a crossroad and/or at other 
selected locations. 

k. Use of Raised, Reflectorized Pavement Markers 

Raised, reflectorized pavement markers may be used to form arrow 
markings and to supplement lane lines. Monodirectional markers 
should be red as viewed-by wrong-way drivers. Bidirectional markers 
should be white as viewed in the direction of traffic, and red, as 
viewed by wrong-way drivers. 



Page 3 

5. Design of VTRONG WAY signs and FREEWAY ENTRANCE signs 

WRONG WAY signs should "be refiectorized and should have a white 
legend in tvo lines and a white "border on a red background. Where 
used in an assecbly, they are to he equal in width to the DO NOT 
ENTER sign. Where installed separately, they are to be a minimum 
of 36" X 2k". FREE\WY ENTRANCE signs, if used, shall be refiectorized 
and shall have a white legend in two lines and a white border on a 
green background. A 36" x 24" ^ize usually will be adequate. 

6. Participation with Federal-aid Funds 

Federal-aid 'nighway funds may be used to provide the signs and markers 
considered necessary to alleviate the hazard of wrong-way movements 
on projects currently under construction and those proposed for the 
future. Federal-aid funds also may be used to provide the signs 
and markers along existing facilities when projects o:^ sufficient 
scope axe presented to assure reasonably efficient and economical 
project administration. See PM 21-15 . 



>^^^^VU^^tA.^ 



F. C. Turner 
Acting Federal Highway 
Administrator 
Enclosure 



TYPICAL REGULATORY Z\m\m Af^D ARROW MARKIS^GS 
AT RAMP TERr/1iNALS 



DIRECTION OF TRAVEL 



ARROW PAVEMENT MARKING 





C/0 

is: 



CO 



CO £5 

>■ ^ 

^ UJ 



cs 



o 

>■ 



C^ 




APPENDIX 4 



HAS_ALCO:^0!. Af rKTEQ YOUR D.^iv/'NG ASIIITY? 

"nw % of ak = :-ol In yc^r flood -.11 :ell you. Th,, r, con be ei.lmarsd by- 
COUSTINC T0U5 DRINKS (l.dr.-b .q^o'l.ng 1 ,cl»rr,<, oi. ol 100 Drool oko'ol 
or I-l? Oi. boilo ol b«ef). 

Uv> SleodA'cohol Chart btlow. Under nurnber of DRINKS ond oppcl. 
lorfy-Wslghr fird th, =i of Slood-Alcohol lined 

SUSTHACT Imm ,h„ „,^ber ,h, % of alcohol "bwrred „p" dying Iho lime 
•lopwd liiico your firu drink. 
No- Moun inc. 1,t Brink '73434 

SUaTSAa ...._ .015% .030% .tU5% ToAO?, ;^J% :o90% 

E»or"pl«-1BO lb. man . a drlnkl in < houri 
.147% m.nu. .0*0% =107% 
THIS REMAINDES IS AN ESTIMATE of ,h, =A of okof«l in your blood. 

IIWTE.gPSFTATION OF RESULT S 
% OF 9I.OOD.ALC0H0 L In"^Ox;CATEd"? Tf'yOU DRIVE A CAR- 

■""' « 050 You Are No. Tok, ll £»„ 

JiO H> .100 You Moy 8, Um E.lren^e Coution 

.100 ID .150 You Probobly Are Bener NaT 

.150 Gr>d abc,. YOU ARE DON T-YOU-VE HAD IT 

FOa (EST RESULTS-OO.NT OSINK AND DRIVE 



BIOOL'-AICOHOL CHART 



SHOWING ESTIMAT£0 % OF ALCOHOL IN THc BLOOD 

yr NO. Of DRiNxs in RELAnom to booy wsight 

i 5 3 4 5 6 7 a 9 10 n 12 



CfilNKS 


S 


ICO lb. 
120 Iti. 


J 


140 lb. 
160 lb. 


lEO lb. 


S 


2C0 ib. 





no Ib. 


A 


240 Ib. 



.033 .075 .113 .ISO .183 .725 .363 .3C0 .333 .375 .413 .450 

.031 .'-S3 .094 .125 .156 .133 .219 .250 281 .313 .344 .375 

.027 .054 .030 .107 .134 .141 .133 .214 .241 J43 .295 .32i 

.023 .047* .070 .094 .117 .141 .144 .183 .211 .234 .253 .281 

.021 .042 .043 .033 .104 .125 .144 .147 .1S3 .203 .229 .250 

.019 .033 .054 .075 .094 .113 .131 .150 .149 .133 .204 .225 

.017 .034 .051 .043 .035 .102 .119 .134 .153 .170 .183 .205 

.014 .031 '.047 .043 .078 094 .109 .125 .141 .154 .172 .133 

Government of the District of Columbia 

DtPARTMENT OF MOTOR VEHICLES 

Office of Traffic Safely Education 



IJ/M— 3CM 



APPENDIX 5 

Uniform Vehicle Code 

Implied Consent 

Pages 69 and 70 



Section 6-205. 1-Revocation of license in event of refusal to subnnit to 
chemical tests'^°^ 

(a) Any person who operates a nnotor vehicle upon the public high- 
ways of this State shall be deemed to have given consent, subject to 

the provisions of section 11-902, to a che"iical test or tests of his blood, 
breath, or urine for the purpose of determining the alcoholic content of 
his blood if arrested for any offense arising out of acts alleged to have 
been committed while the person was driving or in actual physical con- 
trol of a motor vehicle while under the influence of intoxicating liquor. 
The test or tests shall be administered at the direction of a law enforce- 
ment officer having reasonable grounds to believe the person to have 
been driving or in actual physical control of a motor vehicle upon the 
public highways of this State while under the influence of intoxicating 
liquor. The law enforcement agency by which such officer is employed 
shall designate which of the aforesaid tests shall be administered. 

(b) Any person who is dead, unconscious or who is otherwise in 
a condition rendering him incapable of refusal, shall be deemed not 
to have -withdrawn the consent provided by paragraph (a) of this sec- 
tion and the test or tests may be administered, subject to the pro- 
visions of section 11-902. 

(c) If a person under arrest refuses upon the request of a law 
enforcement officer to submit to a chemical test designated by the law 
enforcement agency as provided in paragraph (a) of this section, none 
shall be given, but the department, upon the receipt of a sworn report 
of the law enforcement officer that he had reasonable grounds to 
believe the arrested person had been driving or was in actual physical 
control of a motor vehicle upon the public highways of this State while 
under the influence of intoxicating liquor and that the person had 
refused to submit to the test upon the request of the law enforcement 

'^^^Generally known as the "implied consent law. " A State contem- 
plating the enactment of this section should refer also to sections 
11-902, 11-902.1, 6-208 and 1-155. 



-2- 

officer, shall revoke his license or permit to drive, or any nonresident 
operating privilege; or if the person is a resident without a license or 
permit to operate a motor vehicle in this State, the department shall 
deny to the person the issuance of a license or permit for a period of 
six months after the date of the alleged violation, subject to review as 
hereinafter provided. 

(d) Upon revoking the license or permit to drive or nonresident 
operating privilege of any person, or upon determining that the issu- 
ance of a license or permit shall be denied to the person, as herein- 
before in this section directed, the department shall immediately 
notify the person in writing and upon his request shall afford him an 
opportunity for a hearing in the same manner and under the same 
conditions as is provided in section 6-206(b) for notification and hear- 
ings in the cases of discretionary suspension of licenses, except that 
the scope of such a hearing for the purposes of this section shall cover 
the issues of whether a law enforcement officer had reasonable grounds 
to believe the person had been driving or was in actual physical control 
of a motor vehicle upon the public highways of this State while under 
the influence of intoxicating liquor, whether the person was placed under 
arrest, and whether he refused to submit to the test upon request of the 
officer. Whether the person was informed that his privilege to drive 
would be revoked or denied if he refused to submit to the test shall not 
be an issue. The department shall order that the revocation or deter- 
mination that there should be a denial of issuance either be rescinded 
or sustained. 

(e) If the revocation or determination that there should be a denial 
of issuance is sustained after such a hearing, the person whose license 
or permit to drive or nonresident operating privilege has been revoked, 
or to whom a license or permit is denied, under the provisions of this 
section, shall have the right to file a petition in the appropriate court 
to review the final order of revocation or denial by the department in 
the same manner and under the same conditions as is provided in 
section 6-211 in the cases of discretionary revocations and denials. 

(f) When it has been finally determined under the procedures of 
this section that a nonresident's privilege to operate a motor vehicle 
in this State has been revoked, the department shall give information 
in writing of the action taken to the motor vehicle administrator of 
the state of the person's residence and of any state in which he has a 
license. (NEW SECTION, 1962) 




00 

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Eastbound 

Interstate 15 

to 

Las Vegas 



LEGEND: 

Vehicle No. 1 - Wrong-Way Automobile 

Vehicle No. 2- Bus 




ILLUSTRATION 2 (No Scale) 



Accident diagram showing relative vehicle position during collision and post-collision 
phases of accident. 



FRONT OF BUS 




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KNOWN AND DEDUCED 
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AGES AND SEX OF 
BUS OCCUPANTS 



31 OCCUPANTS 
19 DECEASED 
12 SURVIVORS 

FATALITY 



The Arrow indicates 
the escape route of 
the Survivors. 



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DATE DUE 




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HV 8079.55 .U58 68/12 
Interstate bus - 
automobile collision. 
Interstate Route 15, 



_ .DATE I c^„„ 

HV 8079.55 .U58 68/12 
Interstate bus - 
automobile collision, 
Interstate Route 15, 



NATIONAL EMERGENCY 

TRAINING CENTER 

LEARNING RESOURCE CENTER 

16825 SOUTH SETON AVENUE 
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